Pill Mills: An Overview of Law Enforcement’s Painful Challenge

Rick Ramirez

Abstract

Pharmaceutical drug diversion remains one of the most significant concerns for law enforcement throughout all regions of the State of . This statement is supported by the data and information provided by this article. According to a Florida Medical Examiners Commission Report, painkillers such as and hydrocodone have caused mores deaths than and cocaine. This is a result of the illegal use of prescription drugs. Law enforcement reports that these pharmaceutical drugs should be monitored because of the criminal activity associated with these drugs.

Introduction

Diverting pharmaceutical drugs from their prescribed and appropriate use remains as one of the most significant concerns not only for law enforcement but also to our health care professionals throughout our region of Florida. It is an epidemic causing death due to abuse and diversion of controlled prescription drugs. This is clearly supported by the data provided in the Drugs Identified in Deceased Persons by Florida Medical Examiners report released in June 2009. In the summer of 1992, the Federal Bureau of Investigations (FBI) arrested over 80 pharmacists for Medicaid drug fraud as the result of “Operation Goldpill.” The investigation involved a pharmacy in California that operated as a “pill mill.” Subsequently, patients were paid with in-store merchandise and Medicaid was billed for the prescription. The pharmacy then resold the drugs through unlawful means. Characteristically, these cases involve a scheme between a Medicaid pharmacy and a physician. However, the patients are too often part of the scam. officials estimate that in 1990 “pill mill schemes cost at least $75 million – about 10 percent of the state’s total Medicaid expenditures for prescription drugs.” (Rankin, 1992) Further analysis from law enforcement disclosed that “drug diverters” are stealing prescription drugs and selling them back into the wholesale chain where the products can eventually end up in pharmacies and health facilities without the knowledge of health care providers. (Chambers, 2010) Since 2005, a number of medical facilities throughout the State of Florida were operating as “pill mills.” A “pill mill” describes a doctor’s office, clinic, or other healthcare facility that routinely prescribes or dispenses controlled substances (controlled substances II-V), without a medical necessity and outside the course of a normal professional practice. In essence, pill mills are responsible for dispensing large quantities of pharmaceutical drugs, which are being used and diverted by thousands of Floridians and voyagers from other states. The majority of the “pill mill” facilities have marketed themselves as “ clinics.” However, not all pain management clinics are engaged in criminal activity. Many of these clinics across the state are operating in a legal manner and employ trained personnel and doctors who treat patients who legitimately suffer from pain. According to the American Medical Association, “pain management clinics provide specialized medical treatment to more than 48 million Americans…Treatment ranges from physical therapy to surgery and the prescription of narcotics, including Oxycotin and Xanax.” Further, in 2004, the pharmaceutical industry generated more than $250 billion in painkiller sales, according to industry reports. (Webster, 2005) When a facility is identified as an operational pill mill, characteristically, they may be engaged in insurance, Medicaid, Tri-Care or Medicare fraud by prescribing narcotics that are not medically necessary to the patient. The majority of provider fraud is linked to billing for services not rendered, billing for more expensive services than those actually provided, and billing separately for individual services which normally would be included in one procedure. Many of the pill mills also dispense narcotics on site and many patients are referred to a specific pharmacy recommended by the physician or office personnel in an attempt to mitigate contact with law enforcement. In fact, many of the physicians collude with the pharmacies by either co-owning the pharmacy or receiving kick-backs from the pharmacist. abusers have traditionally acquired the drugs through “doctor shopping”, which is generally the term used when an individual visits multiple doctors complaining of the same symptoms in order to receive multiple prescriptions of the same type.” (FDLE, 2010) Doctor shoppers target legitimate physicians who write control substance prescriptions in good faith, but become prey to fraudulent patient claims. Another overwhelming concern is the pill mill doctors that have been identified as “high prescribers.” These doctors are characterized as overprescribing physicians who are engaged practices outside the normal standard of care. They prescribe the normal “cocktail” of and for cash-only business, with no verification of medical complaints, no meaningful , no diagnostic test, no discussion of treatment plan or alternate treatment, and no assessment of risk of abuse. Additionally, the physician or co-conspirators distribute controlled substances to patients while having the knowledge that the patient was addicted to the controlled substance, and the patient requested additional quantities to support or share with others. Florida leads the nation in prescriptions for oxycodone, the most popular painkiller on the street. Forty percent more oxycodone is prescribed in Florida than the second-leading state, California, which contains double the population. Drug Enforcement Administration (DEA) sources state that their list of hot spots regarding prescription drugs show Tampa Bay, Broward, Palm Beach, Miami-Dade and Hillsborough counties as the lead concern. The hub of distribution for a variety of heavily dispensed pain like hydrocodone and oxycodone continues to revolve around Broward County which alone has over 150 “pain management clinics.” As a result, the southern Florida region continues to be the destination for many “travelers” seeking to obtain prescriptions for pain medications. (FDLE, 2009)

2 According to a Florida Medical Examiner Commission report, illegal use of prescription painkillers oxycodone and hydrocodone is causing more deaths than heroin or cocaine. While the abuse of cocaine and heroin continues its stride, the increasing misuse of pharmaceutical drugs such as , diazepam, oxycodone, hydrocodone, methadone, and morphine has become yet a larger problem in Florida. The examiner’s report indicated that between January and June of 2001, there were 217 deaths caused by lethal doses of either oxycodone or hydrocodone, or a combination of an opiate and a such as oxycodone taken with alprazolam or methadone taken with alprazolam. The report also disclosed that there were 126 heroin-related deaths during the same time period and 183 deaths caused by cocaine. (FDLE, 2009) In an article written by Jeff Kottkamp (2010), “Six Floridians die each day from a prescription – five times as many deaths as from all illegal drugs combined. In fact, the number of drug overdose deaths in Florida increased by 77 percent from 2003 to 2008, and each one involved at least one prescription drug.” (p.3) As indicated by the 2009 Florida Statewide Drug Threat Assessment, “the 2008 Florida Medical Examiners Drug Report totaled 8,556 drug-related deaths. Of those reported deaths, prescription drugs accounted for 75 % of all drug occurrences, where alcohol was excluded. In addition, the report stated that prescription drugs continued to be found more often than illicit drugs in both lethal and non-lethal levels during the year.” (p.29) In a 2009 report authored by the Office of Drug Control (2010), “prescription drug deaths escalated to 2,488,” making prescription drug abuse the number one killer of middle-aged Floridians. In Broward County, 415 people died as the result of misuse of oxycodone, hydrocodone, methadone and morphine. During the same year, Pinellas county authorities arrested 243 people for drug diversion and tended to 179 deaths associated to overdose as the result of prescription drugs. According to a July 2010 report by the United Way of Broward County’s Commission on , rates of oxycodone-related visits to the emergency departments in Broward and Palm Beach counties by people in their 20’s is double the national rate. (Keller, 2011) Kentucky, Tennessee, South Carolina, Georgia, and Alabama have been reported as those common states where most prescription drugs are being transported for distribution. It seems that those states have enacted electronic mechanisms such as prescription drug monitoring programs which eventually cut off all doctor shopping within their respective states. Consequently, prescription drug runners from those states are paid to transport “travelers” in a vehicle who travel through several counties that house pain management clinics, purchase prescriptions or pain killers, and eventually return to their state with vials that contain thousands of prescription drugs. The trend is clear in terms of prescription drugs and pill mills. Advertisement for specific medicines, offers of promotional incentives and discounts for first-time patients in publications, billboards and flyers is alluring. These facilities operate as a cash business with a steady flow of patients that travel as groups. They provide services to hundreds of patients per day and dispense prescription drugs on site or refer their patients to a specific pharmacy. The illegal activity which diverts drugs away from the patients that truly require treatment and into a complex and financially rewarding

3 scheme that involve prescription fraud, drug runners, wholesale buyers, addicts, check cashing centers, physicians, office employees, and pharmacies, has emerged as a major source of crime and wasted spending. Prescription drug diversion increases suffering from drug , costs lives, increases crime, and accelerates costs associated to diversion treatment, medical expenses and insurance fraud.

Methodology

The purpose of this research is to determine the scope of the problem involving pill mills, doctor shoppers, script shoppers, and prescription pill buyers within the eight (8) county region of Tampa Bay. The Tampa Bay Region has two of the top ten counties in Florida (Hillsborough and Pinellas) that have the highest numbers of registered pain clinics with the Florida Department of Health (FDOH). Further, according to the medical examiner these two counties contain the highest statistical data involving usage and deaths associated to alprazine, diazepam, oxycodone, and hydrocodone. The analysis will specifically orientate the Tampa Bay area law enforcement agencies of the diversion drug’s impact on crime and the law enforcement within our community. In order to determine if law enforcement within the Tampa Bay region was experiencing problems with pill mills, a survey conducted by the Florida Department of Law Enforcement (FDLE) polling eight (8) counties and 39 police departments was utilized. A “self-administered questionnaire” was forwarded to all 47 regional agencies via e-mail to capture the information for statistical purpose. The survey contained twelve questions. All but one question required a single response of “yes” or “no”. The last question was opened to a multiple response.

Results

The Tampa Bay region has identified multiple facilities which would fall into the profile of an operational “pill mill”. There are eight counties specifically designated within the Tampa Bay. Those counties include: Hillsborough, Pinellas, Polk, Hardee, Pasco, Hernando, Sumter, and Citrus. All eight counties responded to the survey. Six out of the eight county law enforcement agencies that provide services within the Tampa Bay region affirmed that they were experiencing a high volume of pain management clinics within your area of responsibility. Those counties include Hillsborough, Pinellas, Pasco, Citrus, Sumter, and Hernando. Investigations have identified thirty-four doctors in Hillsborough County that are violators, five which were currently under investigation. Pinellas and Pasco counties reported forty suspected of operating pill mills within their area and seven which were under investigation. Citrus, Sumter, and Hernando counties reported twenty-five doctors suspected of operating pill mills. Table 1 represents the number of pain management clinics registered by county as well as the respective percentage of the total number of clinics. This chart is relevant

4 to the data collected from the survey to obtain a perspective of the problems within the Tampa Bay region.

Pain Management Clinics by County

Registered Clinics by County % of Clinics from the Total

Hillsborough - 150 52.08 %

Pinellas - 62 21.53 %

Pasco - 35 12.50 %

Hernando - 18 3.82 %

Sumter - 11 .69 %

Citrus - 9 3.13 %

Polk - 2 6.25 %

Hardee - 0 0 %

Total 287 100 %

Table 1 The data in this chart was obtained from the Florida Department of Health (FDOH) in 2010. The totals do not represent the pain clinics that may be operating illegally or those that may be pending registration

Table 2 represents the total number of pain management clinics registered by city. This chart is relevant to the data collected from the survey to obtain a good perspective of the problems within the Tampa Bay region.

Total Pain Clinics by City

City/Number City/Number Tampa - 103 Hudson - 2 Clearwater - 22 Indian Shores - 2 Brandon - 19 Riverview - 2 St. Petersburg - 16 Sun City Center - 2 New Port Richie - 15 Beverly Hills - 1 Lakeland - 10 Gulfport - 1 Temple Terrace - 8 Haines City - 1

5 Lutz - 7 Hernando - 1 Plant City - 7 Lake Wales - 1 Largo - 6 Land O Lakes - 1 Palm Harbor - 6 Lecanto - 1 Pinellas park - 6 Port Richey - 1 Spring Hill - 6 Seffner - 1 Brooksville - 5 Seminole - 1 Zephyrhills - 5 South Pasadena - 1 Dade City - 4 The Villages - 1 Winter haven - 4 Thonotosassa - 1 Holiday - 3 Trinity - 1 Wesley Chapel - 3 Hardee - 0 Bayonet Point - 2 Inverness - 6 Davenport - 2 Total: 287

Table 2

The data in this chart was obtained from the Florida Department of Health (FDOH) in 2010. The totals do not represent the pain clinics that may be operating illegally or those that may be pending registration

The majority of agencies that were experiencing suspicious criminal activities with identified pain management clinics were primarily in Hillsborough, Pinellas, and Citrus counties. Only two counties, Pinellas and Hillsborough drafted and implemented city/county ordinance or policies where pain management clinics in violation subsequent to an inspection received an administrative violation. Hillsborough and Pinellas counties reported that overt and tactical/strategic operations were being conducted in an attempt to identify the violators and potential criminals within their jurisdiction.

Table 3 represents the number of active investigations regarding pill mills and scripts conducted by agencies within the Tampa region.

County Script Pill Mill (Includes cities) Investigations Investigations Hillsborough 1 5 Pinellas 5 7 Pasco 0 3 Hernando 1 2 Sumter 0 0 Citrus 1 0 Polk 0 0 Hardee 0 0

Table 3

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The data in this chart was obtained from the Florida Department of Law enforcement (FDLE) in 2010. The totals do not represent those investigations conducted by the Drug Enforcement Administrations (DEA) Task Force

Local agencies throughout the region communicate well regarding “pill mill” investigations, but the volume and cost associated with these cases hinders most agencies. Although the Tampa Bay region has specialized investigators working “pill mill” cases, many agencies still voice the need for more manpower and financing to combat this issue. With the assistance of the Florida Department of Health (FDOH), U.S. Health and Human Services (USHHS), the FBI, and the Attorney General’s Medicaid Fraud Unit (AGMFU), the Pinellas County Sheriff’s Office (PCSO) and the Hernando County Sheriff’s Office (HCSO) have dedicated units that combat the diversion issues within their jurisdiction. Detectives from the Largo Police Department (LPD), the Clearwater Police Department (CPD), and the St. Petersburg Police Department (SPPD) are assigned to the PCSO who purported that they have a dedicated pharmaceutical diversion unit that primarily focuses on the pill abusers and pain management clinics. There is a DEA Tampa, Florida task force which is comprised of members from the following agencies: PCSO, the Lakeland Police Department (LPD), the Polk County Sheriff’s Office (PCSO), Pasco County Sheriff’s Office (PCSO), CPD, and the Tampa Police Department (TPD). Not only is FDLE involved in various investigations with above described units and respective agencies, FDLE shares intelligence for de- confliction purposes with the DEA Task Force. The FDLE, Tampa Bay Regional Operations Center (TBROC) investigations have purported that pill abusers in other Florida counties are commuting to Hillsborough County to get prescriptions and pills. Those counties are Taylor, Alachua, Dixie, and Levy and the city of Gainesville.

Discussion

This research offers information to law enforcement agencies that are combating diversion issues within their jurisdiction. The implications for law enforcement are clear and the data supports the need to investigate and cease diversion of prescription drugs. In order to combat the problem, we must understand the dynamics of a pill mill, the doctors who operate these diversion crimes, and the mechanics of the investigation. A pill mill operation is one of the most difficult investigations to conduct. It requires extensive manpower hours and can become extremely costly when working undercover (U/C) operations in terms of expenses. The majority of the suspected pain management clinics have poor record keeping and management. These pill mills can easy be identified by utilizing U/C agents that have the skills, ability, and knowledge of conducting these types of operations. During the initial visit with a doctor, a U/C can observe and determine if the practice meets the pill mill criteria such as cash-only practice; a brief, cursory medical examination by the doctor who provides no

7 documentation; a doctor coaching patients; lack of diagnostic tests; inappropriate prescription and elevated dosage amounts; and providing no alternative treatment plans. A pain management clinic that is not physician-owned needs only a doctor’s name and license number to dispense . The Board of Medicine will not necessarily hold a doctor responsible if the independently run pain clinic is identified and investigated as a pill mill. Further, the Agency for health Care Administration oversees only clinics that accept insurance. Pill mills predominately operate on a cash- only basis. Additional challenges that impede diversion drug investigations are the “Standard of Care versus Criminal Act.” In other words, good doctor versus bad doctor. Law enforcement must establish that the medical professional’s performance extended outside the usual course of professional practice. During the investigation law enforcement must establish that prescriptions were not issued for a valid or legitimate medical purpose and that a corresponding responsibility rests with the pharmacist who fills the prescription. Investigations require tracking the flow of money because of the cash only businesses. An extensive review of records such as patient files, doctor’s college and medical backgrounds, and standards on physicians that received training outside of the United States are necessary during an investigation. Diversion investigations also require expert opinions and witnesses that are very costly. Drugs being dispensed are predominately Valium, Oxycontin, Xanex, and Somas. The pain management clinics are requiring referrals from doctors and/or a pharmacy summary. Some clinics ask for a Magnetic Renaissance Imaging (MRI) but in some instances U/C officers have not presented MRI’s and still managed to obtain medications. Although transactions with pain clinics are cash-only, pharmacies that collude with the clinics take Medicaid, Medicare, and Tri-Care as a mean of payment. Information regarding pill mills comes from Crime Stoppers, local and county law enforcement agencies, Sheriff’s Tip Line, street sources, doctors, pharmacies and other medical professional. Referrals also come from law enforcement agencies in and out of state, confidential sources, medical examiner reports, regulatory agencies, pharmaceutical wholesalers, and complaints from corporate pharmacies Some barriers that agencies are confronted with include manpower resources and funding due to the volume and cost of pill mill investigations, labor intensive investigations when cases include both healthcare fraud and drug trafficking, and de- confliction problems regarding investigations. In response to Florida’s drug problem, pain management facilities are now required to register with the FDOH. All pain management facilities must be registered by December 1, 2010, per Senate Bill 462; F.S. 458.309. Medical practitioners are subject to discipline if they practice in a pain management clinic that is required to register with the FDOH and has not complied. In an effort to alleviate prescription drug abuse in Florida, the prescription Drug Monitoring Program (PDMP) was passed during the 2009 legislative session. FDOH was required by Florida State Statute 893.055 to establish the PDMP by December 1, 2010. PDMP allows medical professionals to log each filled prescription into a state database to prevent abusers from obtaining prescriptions from multiple doctors. The PDMP is a reality in 34 states and is now federally mandated for Medicaid prescriptions.

8 FDLE along with their regional partners have developed an investigative strategy for diversion/prescription drug and health care fraud.

. Review Medical Examiner’s Files

. Obtain Autopsy Reports & Police Reports

. Identify Target Doctors Seek and review complaints from various agencies Seek fraudulent billing patterns identified Identify pill bottles at crime scenes (seeking specific cocktails) Interview of friends and family of deceased Seek and review former patient and/or employee complainants

. Review General Intelligence to include DEA ARCOS (data of physician’s inventory of dispensed drugs)

. Obtain law enforcement officers/investigators for undercover (U/C) missions

. Recruit “Friendly” Doctors for pre-exam of U/C’s

. Notify the Board of Medicine of “Friendly” Doctor’s Participation

. Obtain Thorough Exam of U/C’s by “Friendly” Doctor Order specialty test, X-ray, MRI Prepare legitimate medical records Obtain referral to pain management from “Friendly” Doctor Obtain “Friendly” Pharmacist Prepare RX summary of U/C’s records based on legitimate prescriptions by “Friendly” doctor

. Obtain Medicare/Medicaid cards for U/C

. Conduct Recorded U/C Meetings with Target Doctor and Co-conspirators Use terms such as stiffness, discomfort, not “Pain” Indicate pain level “zero” or minimal Request increase in dosage unit of prescriptions for controlled substances Request prescriptions of controlled substances for friends and family members not present Advise doctor of sharing of pills with others Request prescriptions for drugs not commonly prescribed in pain management such as dilaudid and demoral. Request payment via insurance

. Conduct surveillance on target site

9 . Conduct local law enforcement undercover ops and arrest drug seeker’s at target sites

. Fill prescriptions at target pharmacy using U/C Medicare/Medicaid card, if possible

. Obtain Medicare/Medicaid data on target pharmacy/medical clinic

. Interview patients regarding health care fraud and prescribing practices

. Expert Witness (Drugs) – Render Opinion

. Expert Witness (Health Care Fraud) – Render Opinion

. Obtain Prosecutorial Direction (federal, state, statewide) Establish the practitioner and/or pharmacist engaged in fraudulent billing among other diversion violations

Some recommendations identified include a streamlined investigative approach such as the creation of a Joint Task force efforts (force-multiplier) to identify the pill mills, coordinate investigative efforts, to eliminate duplication and resources. Designate prosecutors to assist from the initiation of the investigation and creating stricter guidelines for the operation of pain clinics.

Conclusion

Prescription drug abuse is the country's fastest growing substance abuse problem and the Centers for Disease Control and Prevention have classified prescription drug abuse as an epidemic. The illegal diversion and nonmedical use of medications such as pain relievers, tranquilizers, and stimulants is a serious problem in Florida and nationwide. In addition, patients may be denied medication because prescribers fear abuse and diversion. In response to the war against prescription drugs, the Governor of Florida, with the support of the FDLE commissioner, created Florida’s Regional Drug Enforcement Strike Task Force (RDESTF). The mission and goals are alike: to disrupt, dismantle and destroy the targets criminal activities. If possible, identify drug related assets and the manner in which they are being concealed and to mitigate the adverse impact of associated crimes in that jurisdiction that place a burden on the jurisdiction's resources such as overdose deaths, increase addiction to prescription drugs, and finally an overall increase in violent and property crimes. A model was developed by the Department of Health and Human Services, Office of Inspector General (HHS-OIG) for identifying cases that have a health care fraud nexus. These investigations are directly related to Medicare Part B (office claims) Part D (prescription drugs) and Medicaid claims data. This strategy will identify those clinics that are the high dollar billers.

10 Finally, over 34 states have already implemented a Prescription Drug Monitoring Program (PDMP) as part of their efforts to reduce pharmaceutical diversion. This program will mitigate drug seekers from other states that are reportedly traveling to Florida to obtain pills for abuse or illegal sale. The creation and implementation of a PDMP has clearly been identified as an important tool to assist both the medical and criminal justice practitioners in identifying and reacting to “physician shoppers” and the operation of pain management clinics that are circumventing our laws. Additionally, the PDMP would provide honest physicians with an important tool to avoid inappropriate prescriptions. Pursuant to the Governor’s creation of the Regional Drug Enforcement Strike Force, there have been significant successes collaborating with FDLE, HHS-OIG, DOH, and all participating agencies within the Tampa regional that bring forward a successful impact and outcome.

Recommendation

A post-survey and additional research are recommended in an attempt to measure the success and impact of the governor’s strike force and implementation of the PDMP. Further, the collection of the medical examiner’s data of deaths associated to prescription pills for the reporting period of July 1, 2011 through December 31, 2011, add value in determining the success of our state’s strategy against prescription drug abuse.

Assistant Special Agent in Charge Rick Ramirez began his career as a member of the Volusia County Sheriff’s Office where he served as a Deputy Patrolman and investigator for the Special Investigations Unit which included narcotics, vice, and major violent crimes investigations. He joined FDLE in 2000 where he served as a Special Agent for the Orlando regional office, an Inspector for the Office of Executive Investigations in Tallahassee, and is presently assigned as the Assistant Special Agent In- Charge, Chief of Investigative Operations for the Tampa Bay Regional Operations Center. In his present position, he oversees the day to day operations in the criminal investigation’s division, domestic security, mutual aid, and the Protection Operations Services for the Governor and his family while in Tampa.

11 Reference

Florida Department of Law Enforcement. (2009). Medical Examiners 2009 Interim Report of Drugs Detected in Deceased Persons,

Rankin, K. (1992). Pill mill foe? Gov’t. studies hi-teck tracker. Drug Store News, 14, 4(1) Retrieved on February 23, 2011 from http://find.galegroup.com/gps/infomark.do?$contentSet=IAC- Document&type=retrieve&tabID=T003&prodid=IPS&docid=A12550098&source= gale&userG

Chambers, H. (2010). Prescription drug trafficking threat to health care: bootlegging legal drugs through illegal channels a growing concern. San Diego Business Journal. 31, 4, 3(2)

Office of Drug Control. Prescription Drug Monitoring Program (PDMP). (2010, July). What the Program Does and Does Not Accomplish. Florida Webster, A. (2005). “Pain clinics nationwide feel big pinch from cities.” New Orleans City Business : NA. General OneFile.Gale.State Library of Florida –Web Portal 23 Feb.2011. Retrieved on February 23, 2011 from http://find.galegroup.com/gps/infomark.do?$contentSet=IAC- Document&type=retrieve&tabID=T003&prodid=IPS&docid=A132087401&source =gale&userG

Florida Department of Law Enforcement, Office of Statewide Intelligence, Gerald M. Bailey, Commissioner, (2010). Florida 2009 Statewide Drug Threat Assessment Published by the Florida Department of Law Enforcement, Office of Statewide Intelligence

Office of Drug Control. (2010, February) Statewide task force will focus on shutting down “pill mills.” Florida: Jeff Kottkamp

Keller, A. (2011). Snapshots from the prescription drug war: Pill Mills. Florida Trend, 53, 10, 108(1)

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